Application For Certified Copy Of Birth Or Death Certificate - Beaumont Public Health Department Page 3
ADVERTISEMENT
1
2
3NOTARIZED PROOF OF IDENTIFICATION
PART I.
ENTER NAME, DATE AND PLACE OF BIRTH/DEATH, AND NAMES OF PARENTS AS INFORMATION APPEARS ON
BIRTH/DEATH CERTIFICATE
DATE OF BIRTH/DEATH
FULL NAME OF PERSON ON RECORD
PLACE OF BIRTH/DEATH (City or County)
SEX
FULL NAME OF PARENT 1
FULL NAME OF PARENT 2
PART II. ENTER RELATIONSHIP TO PERSON ON RECORD AND THE TYPE OF ID USED.
TYPE AND NUMBER OF ID ACCEPTED WHEN NOTARIZED
NAME AND RELATIONSHIP TO PERSON ON RECORD
AFFIDAVIT OF PERSONAL KNOWLEDGE
PART III. THIS SECTION MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC.
STATE OF
_____________________
COUNTY OF _____________________
Before me on this day appeared ____________________________
___________
(Name)
__________________
(Address)
(City)
(State)
who is related
___
(Relationship)
the contents of this affidavit are true and correct.
Signature of Applicant__________________________________________________
Sworn to and subscribed before me, this ________ day of ______________________, 20 ______.
Signature of Notary Public
(Seal)
Commission Expires
Typed or Printed Name
Street Address
City, State and Zip
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE
STATEMENT ON THIS FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND
A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003)
MAIL THIS SWORN STATEMENT, APPLICATION, PAYMENT, AND A PHOTOCOPY OF YOUR VALID PHOTO ID TO:
Beaumont Public Health - Vital Statistics
P.O.Box 3827
Beaumont, TX 77704-3827
(APPLICATIONS WITHOUT THE SWORN STATEMENT AND PHOTO ID WILL NOT BE PROCESSED)
Page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business